Methods of treating arthritis

ABSTRACT

The present invention provides methods of treating arthritis. A sustained release composition comprising liposomes and one or more therapeutic agent or a pharmaceutically acceptable salt thereof is administered to a subject in need thereof. The liposomes may be in an aqueous suspension. The sustained release composition can be administered intraarticularly.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation application of U.S. patentapplication Ser. No. 14/411,530, filed on Dec. 29, 2014, which is anational stage under 35 U.S.C. 371 of International ApplicationPCT/US2013/049442, filed on Jul. 5, 2013, incorporated by reference,which claims the benefit of priority from U.S. Provisional ApplicationNo. 61/668,446, filed on Jul. 5, 2012 and U.S. Provisional ApplicationNo. 61/791,650 filed Mar. 15, 2013, the entire contents of each of whichare incorporated herein by reference.

BACKGROUND OF THE INVENTION

Osteoarthritis (OA) is the most common type of arthritis and a leadingcause of disability. It is a non-inflammatory, degenerative jointdisease characterized by progressive loss of articular cartilage,subchondral bone sclerosis, osteophyte formation, changes in thesynovial membrane, and an increased volume of synovial fluid withreduced viscosity and hence changed lubrication properties.

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease ofunknown cause. Genetic, environmental, hormonal, immunologic, andinfectious factors can play significant roles. The hallmark feature ofthis condition is persistent symmetric polyarthritis that affects thehands and feet, although any joint lined by a synovial membrane can beinvolved. This is due to the accumulation of and proliferation ofinflammatory cells in the synovial lining, known as synovitis.Extra-articular involvement of organs such as the skin, heart, lungs,and eyes can be significant.

Intraarticular (IA) drug injection is an attractive treatment approachfor treatment of arthritis, including OA and RA. The various steroid andhyaluronic acid formulations on the market are considered effective, butrequire frequent IA injections and provide only short-term symptomaticrelief. Other crystal suspension formulations, which require large boreneedles for IA injection are not suitable for treating small joints andcan produce a crystal-induced synovitis. The available systemictreatments also have shortcomings, most notably side effects.

In view of the deficiencies outlined above, there is a need for methodsfor treating arthritis with less frequent IA injection and/orlonger-term pain relief. The methods disclosed herein address this needas well as other important needs.

BRIEF SUMMARY OF THE INVENTION

The terms “invention,” “the invention,” “this invention” and “thepresent invention” used herein are intended to refer broadly to all ofthe subject matter of this patent application and the claims below.Statements containing these terms should be understood not to limit thesubject matter described herein or to limit the meaning or scope of thepatent claims below. This summary is a high-level overview of variousaspects of the invention and introduces some of the concepts that arefurther described in the Detailed Description section below. Thissummary is not intended to identify key or essential features of theclaimed subject matter, nor is it intended to be used in isolation todetermine the scope of the claimed subject matter. The subject mattershould be understood by reference to appropriate portions of the entirespecification, any or all drawings and each claim.

The present invention is directed to methods of treating arthritis,comprising intraarticularly injecting into a subject in need of suchtreatment a sustained release composition, whereby the arthritissymptoms in the subject are reduced. The present invention isparticularly useful for treating rheumatoid arthritis.

The sustained release composition of the present invention comprisesliposomes comprising (a) a phospholipid or a mixture of phospholipids,and cholesterol; and (b) a therapeutic agent or a pharmaceuticallyacceptable salt thereof, wherein the liposomes are in an aqueoussuspension. The sustained release composition can be prepared by mixinga lipid cake with a therapeutic agent.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a line plot showing the changes in body weight in 4 groups ofrats alter each group was subjected, respectively, to a single IAinjection of saline, free dexamethasone sodium phosphate (DSP) or thesustained release compositions.

FIG. 2 is a line plot showing the changes in clinical visual arthritisscore in 4 groups of rats after each group was subjected, respectively,to a single IA injection of saline, free DSP or the sustained releasecompositions.

FIG. 3 is a line plot showing the changes in right ankle volume in 4groups of rats after each group was subjected, respectively, to a singleIA injection of saline, free DSP or the sustained release compositions.

FIG. 4 is a line plot showing the changes in the left ankle volume in 4groups of rats after each group was subjected, respectively, to a singleIA injection of saline, free DSP or the sustained release compositions.

FIG. 5 is a line plot showing the changes in body weight in 3 groups ofrats after four daily IA injections of free DSP or the sustained releasecompositions.

FIG. 6 is a line plot showing the changes in clinical visual arthritisscore in 3 groups of rats after each group was subjected, respectively,to four daily IA injections of free DSP or the sustained releasecompositions.

FIG. 7 is a line plot showing the changes in right ankle volume in 3groups of rats after each group was subjected, respectively, to fourdaily IA injections of free DSP or the sustained release compositions.

FIG. 8 is a line plot showing the changes in the left ankle volume in 3groups of rats after each group was subjected, respectively, to fourdaily IA injections of free DSP or the sustained release compositions.

FIG. 9 is a line plot showing the changes in weight (panel a) andclinical arthritis score (panel b) of the three groups of rats afterfive daily IA injections of free indomethacin or indomethacin sustainedrelease composition. The first arrow on day 19 indicates the first dailyIA administration of indomethacin and the second arrow on day 23indicates the last daily IA administration of indomethacin.

FIG. 10 is a line plot showing the changes in weight (panel a) andclinical arthritis score (panel b) of the three groups of rats after twoIA injections of free etanercept or etanercept sustained releasecomposition. The first arrow on day 23 indicates the first IAadministrations of etanercept, and the second arrow on day 26 indicatesthe second IA administration of etanercept.

FIG. 11 is a line plot showing the changes in weight (panel a) andclinical arthritis score (panel b) of the three groups of rats after twoIA injections of free methotrexate or methotrexate sustained releasecomposition. The first arrow on day 23 indicates the first IAadministration of methotrexate and the second arrow on day 26 indicatesthe second IA administration of methotrexate.

DETAILED DESCRIPTION OF THE INVENTION

As disclosed herein, it was discovered that IA administration to asubject of an effective amount of a sustained release compositiondescribed herein, can advantageously reduce signs and/or symptoms ofarthritis in the subject. It was also discovered that the arthritistreatments disclosed herein can require less frequent IA injections thanpreviously known treatments. Also discovered was that the arthritistreatments disclosed herein lead to longer-term pain relief thanpreviously known treatments. These discoveries are embodied in themethods, compositions and medicaments for treating arthritis, describedherein, as well as in the uses of the compositions for treatingarthritis.

Definitions

As employed above and throughout the disclosure, the following terms,unless otherwise indicated, shall be understood to have the followingmeanings.

As used herein, the singular forms “a,” “an,” and “the” include theplural reference unless the context clearly indicates otherwise.

The term “liposome,” “liposomes” and the related terms, as used herein,include multivesicular liposome (MVL), multi-lammellar vesicles (MLV) orsmall or large unilammellar vesicles (ULV). The liposomes are nano-sizedand comprise a particle-forming component and an agent-carryingcomponent. The particle-forming component forms an enclosed lipidbarrier, substantially free of neutral lipid such as triglyceride. Incertain embodiments, there is less than about 0.1% of neutral lipid inthe particle-forming component. In other embodiments, there is noneutral lipid in the particle-forming component. The agent carryingcomponent comprises a substantially aqueous medium, substantially freeof neutral lipid, such as triglyceride, non-aqueous phase (oil phase),water-oil emulsions or other mixtures containing non-aqueous phase.

The term “effective amount,” as used herein, refers to a dose of thesustained release composition that is sufficient to reduce the symptomsand/or signs of arthritis, such as pain and joint stiffness.

The term “treating,” “treated,” or “treatment” as used herein includespreventative (e.g. prophylactic), palliative, and curative methods, usesor results. The terms “treatment” or “treatments” can also refer tocompositions, such as pharmaceutical compositions, or medicaments.

Throughout this application, by treating is meant a method of reducingor delaying one or more effects or symptoms of arthritis. Treatment canalso refer to a method of reducing the underlying pathology rather thanjust the symptoms. The treatment can be any reduction and can be, but isnot limited to, the complete ablation of arthritis, signs or symptoms ofarthritis. Treatment can include the complete amelioration of arthritisas detected by art-known techniques. Art recognized methods areavailable to detect arthritis and its symptoms. These include, but arenot limited to, radiological examination, joint aspiration, blood tests(for example, detection of rheumatoid factors or an anti-CCP test) orMRI, to name a few. For example, a disclosed method is considered to bea treatment if there is about a 10% reduction in one or more symptoms ofarthritis in a subject when compared to the subject prior to treatmentor control subjects. Thus, the reduction can be about a 10, 20, 30, 40,50, 60, 70, 80, 90, 100%, or any amount of reduction in between.

As utilized herein, by prevent, preventing, or prevention is meant amethod of precluding, delaying, averting, obviating, forestalling,stopping, or hindering the onset, incidence, severity, or recurrence ofarthritis. For example, the disclosed method is considered to be aprevention if there is a reduction or delay in onset, incidence,severity, or recurrence of arthritis or one or more symptoms ofarthritis (for example, pain, stiffness, fever, joint inflammation orjoint tenderness) in a subject susceptible to arthritis as compared tocontrol subjects susceptible to arthritis that did not receive atreatment disclosed herein. The disclosed method is also considered tobe a prevention if there is a reduction or delay in onset, incidence,severity, or recurrence of arthritis or one or more symptoms ofarthritis in a subject susceptible to arthritis after receiving atreatment disclosed herein as compared to the subject's progressionprior to receiving treatment. Thus, the reduction or delay in onset,incidence, severity, or recurrence of arthritis can be about a 10, 20,30, 40, 50, 60, 70, 80, 90, 100%, or any amount of reduction in between.

The term “subject” can refer to a vertebrate having arthritis or to avertebrate deemed to be in need of arthritis treatment. Subjects includewarm-blooded animals, such as mammals, such as a primate, and, morepreferably, a human. Non-human primates are subjects as well. The termsubject includes domesticated animals, such as cats, dogs, etc.,livestock (for example, cattle, horses, pigs, sheep, goats, etc.) andlaboratory animals (for example, mouse, rabbit, rat, gerbil guinea pig,etc.). Thus, veterinary uses and medical formulations are contemplatedherein. The term “arthritis” refers to a joint disorder or conditionthat involves inflammation of one or more joints. The term “arthritis,”as used herein, encompasses a variety of types and subtypes of arthritisof various etiologies and causes, either known or unknown, including,but not limited to, rheumatoid arthritis, osteoarthritis, infectiousarthritis, psoriatic arthritis, gouty arthritis, and lupus-relatedarthritis.

Lipid Cake

A lipid cake used in the arthritis treatments described herein containsa solid lipid mixture in a cake, film or powder form.

In certain embodiments, the phospholipid and cholesterol, or mixture ofphospholipids and cholesterol are pre-formed into liposomes beforefurther processing into a lipid cake.

In certain embodiments, the phospholipid and cholesterol, or mixture ofphospholipids and cholesterol are not pre-formed into liposomes beforefurther processing into a lipid cake.

A lipid cake can be prepared from a variety of lipids capable of eitherforming or being incorporated into a unilayer or bilayer structure. Thelipid cakes provided herein include one or more phospholipids andcholesterol, substantially free of neutral lipid such as triglyceride.Examples of the phospholipids include, but are not limited to,phosphatidylcholine (PC), phosphatidylglycerol (PG),phosphatidylethanolamine (PE), phosphatidylserine (PS), phosphatidicacid (PA), phosphatidylinositol (PI), egg phosphatidylcholine (EPC), eggphosphatidylglycerol (EPG), egg phosphatidylethanolamine (EPE), eggphosphatidylserine (EPS), egg phosphatidic acid (EPA), eggphosphatidylinositol (EPI), soy phosphatidylcholine (SPC), soyphosphatidylglycerol (SPG), soy phosphatidylethanolamine (SPE), soyphosphatidylserine (SPS), soy phosphatidic acid (SPA), soyphosphatidylinositol (SPI), dipalmitoylphosphatidylcholine (DPPC),1,2-dioleoyl-sn-glycero-3-phosphatidylcholine (DOPC),dimyristoylphosphatidylcholine (DMPC), dipalmitoylphosphatidylglycerol(DPPG), dioleoylphosphatidylglycerol (DOPG),dimyristoylphosphatidylglycerol (DMPG), hexadecylphosphocholine (HEPC),hydrogenated soy phosphatidylcholine (HSPC),distearoylphosphatidylcholine (DSPC), distearoylphosphatidylglycerol(DSPG), dioleoylphosphatidylethanolamine (DOPE),palmitoylstearoylphosphatidylcholine (PSPC),palmitoylstearoylphosphatidylglycerol (PSPG),monooleoylphosphatidylethanolamine (MOPE),1-palmitoyl-2-oleoyl-sn-glycero-3-phosphatidylcholine (POPC),polyethyleneglycol distearoylphosphatidylethanolamine (PEG-DSPE),dipalmitoylphosphatidylserine (DPPS),1,2-dioleoyl-sn-glyccro-3-phosphatidylserine (DOPS),dimyristoylphosphatidylserine (DMPS), distearoylphosphatidylserine(DSPS), dipalmitoylphosphatidic acid (DPPA),1,2-dioleoyl-sn-glycero-3-phosphatidic acid (DOPA),dimyristoylphosphatidic acid (DMPA), distearoylphosphatidic acid (DSPA),dipalmitoylphosphatidylinositol (DPPI),1,2-dioleoyl-sn-glycero-3-phosphatidylinositol (DOPI),dimyristoylphosphatidylinositol (DMPI), distearoylphosphatidylinositol(DSPI). Lipids can be mixtures of one or more of the foregoing lipids,or mixtures of one or more of the foregoing lipids with one or moreother lipids not listed above.

In an exemplary embodiment, a lipid cake comprises a mixture of twophospholipids, such as DOPC or DOPG. In another embodiment, the lipidcake comprises a mixture of phospholipids selected from the groupconsisting of DOPC, POPC, SPC, EPC, PEG-DSPE and DOPG and cholesterol.In another embodiment, the lipid cake comprises a mixture of a firstphospholipid and a second phospholipid, the first phospholipid beingDOPC, POPC, SPC, or EPC and the second phospholipid being PEG-DSPE orDOPG. Various exemplary compositions of the lipid cake are disclosed inU.S. application Ser. No. 12/538,435, the teachings of which areincorporated herein by reference in their entirety.

In an exemplary embodiment, the lipid cake mixture comprises DOPC, DOPGand cholesterol at a molar ratio of about 29.5% to 90%:3% to 37.5%:10%to 33%. In another embodiment, the ratio of DOPC:DOPG:cholesterol isabout 56.25-72.5:7.5-18.75:20-25 by mole percent. For example, and notto be limiting, the ratio of DOPC:DOPG:cholesterol can be about67.5:7.5:25. In another embodiment, the lipid cake mixture comprisesabout 12 mole % to less than about 30 mole % of cholesterol relative tothe lipid cake. In another embodiment, the lipid cake mixture comprisesabout 15 mole % to about 29 mole % of cholesterol relative to the lipidcake. In yet another embodiment, the lipid cake mixture comprises about17.5 mole percent to about 28 mole % of cholesterol relative to thelipid cake.

In another embodiment, the particle-forming component is free of fattyacid or cationic lipid (i.e. a lipid carrying a net positive charge atphysiological pH).

In another embodiment, the particle-forming component includes ahydrophilic polymer with a long chain of highly hydrated flexibleneutral polymer attached to a phospholipid molecule. Without being boundby any theory, the hydrophilic polymer is believed to stabilize theliposome and result in a longer circulation time in vivo. Examples ofthe hydrophilic polymer include, but are not limited to, polyethyleneglycol (PEG) with a molecular weight of about 2,000 to about 5.000daltons, methoxy PEG (mPEG), ganglioside GM₁, polysialic acid,polylactic (also termed polylactide), polyglycolic acid (also termedpolyglycolide), apolylacticpolyglycolic acid, polyvinyl alcohol,polyvinylpyrrolidone, polymethoxazoline, polyethyloxazoline,polyhydroxyethyloxazoline, polyhydroxypropyloxazoline, polyaspartamide,polyhydroxypropyl methacrylamide, polymethacrylamide,polydimethylacrylamide, polyvinylmethylether, polyhydroxyethyl acrylate,derivatized celluloses such as hydroxymethylcellulose orhydroxyethylcellulose and synthetic polymers.

1 The particle-forming component may further comprise a lipid-conjugateof an antibody or a peptide that acts as a targeting moiety to enablethe liposome to specifically bind to a target cell bearing a targetmolecule. Examples of the target molecules include, but are not limitedto, epidermal growth factor receptor (EGFR), vascular endothelial growthfactor receptor (VEGF), carcinoembryonic antigen (CEA), and erbB-2/neu(HER2).

The liposomes used in the arthritis treatments described herein can begenerated by conventional techniques used to prepare vesicles. Thesetechniques include the ether injection method (Deamer et at., Acad. Sci.(1978) 308: 250), the surfactant method (Brunner et al., Biochim.Biophys. Acta (1976) 455: 322), the freeze-thaw method (Pick et al.,Arch. Biochim. Biophys. (1981) 212: 186), the reverse-phase evaporationmethod (Szoka et al., Biochim. Biophys. Acta. (1980) 601: 559 71), theultrasonic treatment method (Huang et al., Biochemistry (1969) 8: 344),the ethanol injection method (Kremer et al., Biochemistry (1977) 16:3932), the extrusion method (Hope et al., Biochim. Biophys. Acts (1985)812:55 65), the French press method (Barenholz et al., FEBS Lett. (1979)99: 210) and methods detailed in Szoka. F., Jr., et al., Ann. Rev.Biophys. Bioeng. 9:467 (1980). All of the references set forth abovedescribe the processes and conventional technologies for the formationof liposome vesicles, and the descriptions of these processes areincorporated by reference herein.

In an exemplary embodiment, the therapeutic agent is encapsulated in theagent carrying component of the liposome, wherein the agent carryingcomponent comprises a substantially aqueous medium, substantially freeof neutral lipid, such as triglyceride, a non-aqueous phase (oil phase),water-oil emulsions or other mixtures containing a non-aqueous phase. Anagent carrying component comprising a substantially aqueous mediumprovides longer therapeutic efficacy and a prolonged release profile ofthe therapeutic agent in the joint. In contrast, a therapeutic agentencapsulated in an agent carrying component comprising substantiallynon-aqueous medium (e.g. soy bean oil medium) has a more rapid releaseprofile and shorter therapeutic efficacy. (Bias et al, Sustained-ReleaseDexamethasone Palmitate—Pharmacokinetics and Efficacy in Patients withActivated Inflammatory Osteoarthritis of the Knee. Clin Drug Invest2001; 21(6):429-436.)

In certain embodiments, a lipid cake comprises one or more lipids thatare not pre-formed into liposomes. The lipid cake can be prepared bydissolving the lipids in a suitable organic solvent, including, but notlimited to, ethanol, methanol, t-butyl alcohol, ether and chloroform,and drying by heating, vacuum evaporation, nitrogen evaporation,lyophilization, or other conventional means of solvent removal.

After sterilization, the lipid solution is mixed with the therapeuticagent and lyophilized to form a powder or a cake. Generally, at leastone cryoprotectant and at least one buffer are added to effectivelylyophilize the steroid-lipid mixture.

The cryoprotectants include, but are not limited to, mannitol, glycerol,dextrose, sucrose, and/or trehalose. One exemplary cryoprotectant ismannitol.

The buffers include, but are not limited to, sodium phosphate monobasicdihydrate and sodium phosphate dibasic anhydrous.

Some examples of lipid cake preparation are described below toillustrate the processes of lipid cake preparation as they relate to thepresent invention.

Therapeutic Agent

A therapeutic agent can be a steroid solution, a nonsteroidalanti-inflammatory drug (NSAID) such as indomethacin, a disease-modifyinganti-rheumatic drug (DMARD) or a combination of two or more of theforegoing, as well as a combination of one or more of the foregoing withother ingredients or compounds not specifically listed herein. DMARDsinclude small molecule agents, such as methotrexate, leflunomide,sulfasalazine, cyclophosphamide, azathioprine, cyclosporin A,d-penicillamine, antimalarial drugs (e.g. hydroxychloroquine). DMARDsalso include biological substances, such as a Tumor necrosis factor a(TNF-a) antagonist (e.g. Etanercept, trade name Enbrel, commerciallyavailable from Wyeth Pharmaceuticals, Inc., Collegeville. USA,Adalimumab, trade name HUMIRA, commercially available from AbbottLaboratories, Abbott Park, Ill., USA), interleukin-1 receptorantagonist, interleukin-6 receptor antagonist, anti-CD20 monoclonalantibody, CTLA-4-Ig, RGD peptide and the like.

In an exemplary embodiment, the therapeutic agent is a substantiallywater soluble steroid solution, such as DSP. In another exemplaryembodiment, the therapeutic agent is a substantially water solubleNSAID, such as a pharmaceutically acceptable salt of indomethacin. Inyet another exemplary embodiment, the therapeutic agent is asubstantially water soluble DMARD, such as a pharmaceutically acceptablesalt of methotrexate, or a TNF-a antagonist. In yet another exemplaryembodiment, the therapeutic agent is not covalently bound to aphospholipid or a fatty acid, such as palmitate.

A therapeutic agent or agents can be combined with pharmaceuticallyacceptable excipients and other ingredients suitable for pharmaceuticalformulations (which include formulations for human and animal use, andformulations for research, experimental and related uses). In someembodiments, a citrate buffer is used, preferably sodium citrate. Inother embodiments, a chelating agent is used, preferably EDTA.

Water soluble steroids include any naturally occurring steroid hormones,synthetic steroids and their derivatives. Water soluble steroidsinclude, but are not limited to, cortisone, hydrocortisone,prednisolone, methylprednisolone, prednisone, dexamethasone sodiumphosphate (DSP), hydrocortisone-17-valerate, fluorocortisone,fludrocortisone, methylprednisolone, paramethasone and eplerenone. Inone example, and not to be limiting, a water soluble steroid is DSP. Forinstance, about 2 to about 100 mg/mL of DSP solution can be used toreconstitute the lipid cake.

Pharmaceutically acceptable salts of water soluble steroids includenon-toxic salts formed from non-toxic inorganic or organic bases. Forexample, non-toxic salts can be formed with inorganic bases, such as analkali or alkaline earth metal hydroxide, e.g., potassium, sodium,lithium, calcium, or magnesium, or with organic bases, such as an amineand the like.

Pharmaceutically acceptable salts of water soluble steroids also includenon-toxic salts formed from non-toxic inorganic or organic acids.Examples of organic and inorganic acids arehydrochloric, sulfuric,phosphoric, acetic, succinic, citric, lactic, maleic, fumaric, palmitic,cholic, pamoic, mucic, D-glutamic, glutaric, glycolic, phthalic,tartaric, lauric, stearic, salicylic, sorbic, benzoic acids and thelike.

Sustained Release Composition

Sustained release compositions employed in the arthritis treatmentsdescribed herein are substantially free of crystal suspension. In anexemplary embodiment, there is less than about 0.1% of crystalsuspension in the sustained release composition. In another embodiment,there is no crystal suspension in the sustained release composition. Thesustained release compositions set forth herein comprise liposomes,wherein the liposomes comprise a phospholipid or mixture ofphospholipids, cholesterol, and one or more therapeutic agents, andwherein the liposomes are in an aqueous suspension. The sustainedrelease composition can be prepared by reconstituting a lyophilizedlipid cake comprising one or more phospholipids, and cholesterol with anaqueous solution comprising one or more therapeutic agents to form anaqueous suspension. The sustained release composition can also beprepared by reconstituting a lyophilized combination of one or moretherapeutic agents and a lipid cake comprising one or morephospholipids, and cholesterol with an aqueous solution to form anaqueous suspension. In some exemplary embodiments, the lipid cakeconsists essentially of one or more phospholipids and cholesterol as thelipid components. Suitable aqueous solutions or media for reconstitutioninclude, but are not limited to, buffers, distilled water, saline, asugar solution, for example, a dextrose solution, and the like. In otherexemplary embodiments, the lipid cake consists essentially of aphosphatidylcholine lipid, a phosphatidylglycerol lipid and cholesterol.In yet other exemplary embodiments, the lipid cake can contain (inaddition to the phosphatidylcholine, phosphatidylglycerol, andcholesterol lipids) a preservative, a cryoprotectant or combinationthereof. Further provided herein are sustained release compositionscomprising liposomes wherein the liposomes comprise a phospholipid ormixture of phospholipids, cholesterol, and a TNF-alpha antagonist, forexample, etanercept or adalimumab, and wherein the liposomes are in anaqueous suspension. The lyophilized form of this composition is alsocontemplated herein.

In some embodiments, the sustained release composition further comprisesat least one pharmaceutically acceptable excipient, diluent, vehicle,carrier, medium for the active ingredient, a preservative,cryoprotectant or a combination thereof.

In an exemplary embodiment, the sustained release composition of thepresent invention is prepared by making the lipid cake andreconstituting it with the therapeutic agent to form an aqueoussuspension.

In another embodiment, the sustained release composition of the presentinvention is prepared by adding the therapeutic agent in the lipidmixture during the preparation of the lipid cake, followed bylyophilizing the combination of the lipid mixture and the therapeuticagent with one or more cryoprotectants to form a powder.

In an exemplary embodiment, the sustained release composition comprisesa water soluble steroid with a potency equivalent to about a 2 mg doseto about a 8 mg dose of dexamethasone. For example, the potency of 4 mgDSP in the sustained release composition is equivalent to the potency of3 my dexamethasone. The potency of 10 mg of DSP in the sustained releasecomposition is equivalent to the potency of 7.6 mg dexamethasone.Similarly, the potency of 40 mg methylprednisolone acetate is equivalentto the potency of 7.5 mg dexamethasone.

The sustained release compositions described herein can be used to treata subject suffering from arthritis, such as rheumatoid arthritis.

In an exemplary embodiment, about 50% to about 95% of the therapeuticagent in the sustained release composition is in non-associated form(i.e. about 5% to about 50% of the therapeutic agent is in associatedform). In another embodiment, about 60-90% of the therapeutic agent inthe sustained release composition is in non-associated form. The term“therapeutic agent in non-associated form” refers to the therapeuticmolecules separable via gel filtration from the phospholipid/cholesterolfraction of the sustained release composition.

In another embodiment, the weight ratio of the phospholipid andcholesterol in combination to the therapeutic agent is about 5-80 toabout 1. In yet another embodiment, the weight ratio of the phospholipidand cholesterol in combination to the therapeutic agent is 5-40 to 1.For example, the weight ratio of the phospholipid and cholesterol incombination to the therapeutic agent can be about 5, 10, 15, 20, 25, 30,35, 40, 45, 50, 55, 60, 65, 70, 75 or 80 to about 1.

Methods of Treating Arthritis

The invention is directed to methods of treating arthritis in a subject,which comprise the administration of an effective amount of thesustained release composition as described herein to a subject in needthereof, whereby the symptoms and/or signs of the arthritis in thesubject are reduced.

The sustained release composition is formulated to be suitable for IA,intramuscular or subcutaneous administration. Intra-articular injectioninvolves the following steps: 1) Identifying and marking an appropriateinjection site of the joint to be treated; 2) Sterilizing the injectionsite using aseptic technique and optionally providing local anesthetic.3) Inserting the needle at the injection site into the joint space. Theneedle insertion can optionally be performed under ultrasound guidance.A small amount of synovial fluid is aspirated to confirm that the tip ofthe needle is within the joint space. 4) Injecting the medication intothe joint space.

The dosage of the sustained release composition of the present inventioncan be determined by the skilled person in the art according to theembodiments. Unit doses or multiple dose forms are contemplated, eachoffering advantages in certain clinical settings. According to thepresent invention, the actual amount of the sustained releasecomposition to be administered can vary in accordance with the age,weight, condition of the subject to be treated, the type of joint anddepends on the discretion of medical professionals.

The dose of DSP for an IA injection depends on the condition of thepatient and the size of the joint. In an exemplary embodiment, the doseof DPS is about 0.2 mg to about 6 mg per IA injection. In anotherexemplary embodiment, the dose of DPS is about 2 to about 4 mg per IAinjection for a large joint, such as a knee joint. In yet anotherexemplary embodiment, the dose of DSP is about 0.8 to about 1 mg per IAinjection for a small joint, such as the interphalangeal joint.

In an exemplary embodiment, the dose of indomethacin per IA injection isabout 5 mg to about 30 mg. In another exemplary embodiment, the dose ofindomethacin per IA injection is about 10 to about 25 mg. In yet anotherexemplary embodiment, the dose of indomethacin per IA injection is about15 to about 20 mg.

In an exemplary embodiment, the dose of methotrexate per IA injection isabout 1 mg to about 15 mg. In another exemplary embodiment, the dose ofmethotrexate per IA injection is about 5 mg to about 12.5 mg. In yetanother exemplary embodiment, the dose of methotrexate per IA injectionis about 7.5 mg to about 10 mg.

The frequency of the IA injection ranges from daily, once every three tofive days, weekly or once every two to three weeks.

The following examples will serve to further illustrate the presentinvention without, at the same time, however, constituting anylimitation thereof. On the contrary, it is to be clearly understood thatresort may be had to various embodiments, modifications and equivalentsthereof which, after reading the description herein, may suggestthemselves to those skilled in the art without departing from the spiritof the invention. During the studies described in the followingexamples, conventional procedures were followed, unless otherwisestated. Some of the procedures are described below for illustrativepurpose. Publications cited herein and the material for which they arecited are hereby specifically incorporated by reference in theirentireties. A number of embodiments have been described. Nevertheless,it will be understood that various modifications may be made.Accordingly, other embodiments are within the scope of the followingclaims.

EXAMPLES Example 1: Preparation of a Lipid Cake

A lipid cake was prepared by the solvent injection method. The lipids,including DOPC, DOPG and cholesterol, were combined at a mole ratio of67.5:7.5:25 and dissolved in 99.9% ethanol at about 40° C. in a flask. Atabletop ultrasonic bath was used for lipid dissolution.

The dissolved lipid solution was added to the 1.0 mM sodium phosphatesolution at 100 mL/min by a peristaltic pump, and the two solutions weremixed. The lipid mixture was then passed 6-10 times through apolycarbonate membrane with a pore size of 0.2 μm. Liposomes (or largemultilamellar vesicles (MLVs)) were formed and the average vesiclediameter was about 120-140 nm (measured by Malvern ZetaSizer Nano ZS-90,Malvern Instruments Ltd, Worcestershire, UK).

The liposome mixture was dialyzed and concentrated by a tangential flowfiltration system with Millipore Pellicon 2 Mini Ultrafiltration ModuleBiomax-100C (0.1 m²) (Millipore Corporation, Billerica, Mass., USA) andthen sterilized using a 0.2 μm sterile filter.

The lipid concentration of the filtered liposome mixture was quantifiedby phosphorous assay and the liposome mixture was formulated withcryoprotectent, 2% mannitol and then sterilized again using a 0.2 μmsterile filter. The sterilized liposome mixture was then filledaseptically into vials for lyophilization.

Example 2: Preparation of a DSP Sustained Release Composition

A sustained release composition was prepared by mixing the liposomemixture described in Example 1 with a DSP solution, which comprises DSP(13.2 mg/ml) and sodium citrate (4 mg/ml), followed by lyophilization.

The lyophilized DSP-liposome cake was reconstituted with 300 μl ofsaline, wherein the concentration of DSP was 6.6 mg/ml. The lyophilizedDSP-liposome cake was further diluted with normal saline to form thesustained release compositions as shown in Table 1, wherein theconcentration of DSP was 1 mg/ml in sustained release composition 1 and1.4 mg/ml in sustained release composition 2.

TABLE 1 Composition of the Sustained Release Compositions DOPC DOPGcholesterol mannitol DSP Sustained Released Composition 1 (mg/ml) 10.61.2 2.0 4.3 1 Sustained Released Composition 2 (mg/ml) 14.8 1.7 2.7 6.01.4

Example 3. A Single Injection of Sustained Release Compositions forTreating Arthritis

An in vivo evaluation of the effect of the sustained release compositionon arthritis was performed using Lewis rats. Sixteen female rats, aged 8weeks, were used in the study. The average body weight of the rats wasfrom about 180 to about 200 grams.

To induce arthritis, each rat was immunized with 200 μg of bovine typeII collagen (4 mg/ml stocked in 10 mM acetic acid, commerciallyavailable from Elastin Products, Owensville, USA) emulsified in Freund'sincomplete adjuvant (commercially available from Sigma Chemical Co.,USA) on day 0 and then again on day 7. Day 16 was the first day thatarthritic symptoms were observed and was defined to be the onset ofinduced arthritis.

All the rats in the experimental study had free access to drinking waterand food at all times during this study.

The rats were randomized into the following 4 study groups:

Group 1: 4 rats each received 100 μl of saline per paw (labeled “SalineControl in FIGS. 1-8)

Group 2: 4 rats each received 100 μl of free DSP per paw, wherein theconcentration of DSP is 1 mg/ml (labeled “Free DSP_1 mg/ml” in FIGS.1-8).

Group 3: 4 rats each received 100 μl of the sustained releasecomposition 1 per paw, wherein the concentration of DSP is 1 mg/ml(labeled “TLC399_1 mg/mg in FIGS. 1-4 and “TLC399_I 4 mg/ml in FIGS.5-8).

Group 4. 4 rats each received 100 μl of the sustained releasecomposition 2 per paw, wherein the concentration of DSP is 1.4 mg/ml(labeled “TLC399_1.4 mg/mg in FIGS. 1-4 and “TLC399_II 1.4 mg/ml inFIGS. 5-8).

The control or the DSP formulation was administered to both hind paws ofthe rat as a once only IA injection on day 19. The DSP dose administeredto each paw is summarized in Table 2.

TABLE 2 The characteristics of the sustained release compositions FreeDSP (mg/ml), Dose Total No. of based on volume paw (No. of DSP Conc.encapsulated Group Number (μl/paw) rats) (mg/mL) efficiency % Group 1(Saline) 100 8 (4) 0 0 Group 2 100 8 (4) 1 1 (Free DSP in Saline) Group3 100 8 (4) 1 0.685 (Sustained Release Composition 1) Group 4 100 8 (4)1.4 0.959 (Sustained Release Composition 2)

During the 14-day study period, the rats were examined 3 times a weekfor the following outcomes:

-   -   Body weight loss, which is one of the parameters for evaluating        the severity of arthritis.    -   Clinical Visual Arthritis Score, which is a visual score which        correlates with the severity of arthritis. It was graded using        an articular index of each paw, ranging from 0 to 4 (0=no edema        or erythema on the foot pad; 1=slight edema and erythema on the        foot pad; 2=mild edema and erythema on the foot pad; 3=moderate        edema and erythema on the entire foot pad and the ankle;        4=severe edema and joint rigidity of the ankle, foot and        digits). The Clinical Visual Arthritis Score for each rat was        the sum of the articular index of both hind paws, with a maximum        score of 8.    -   Hind paw volume and swelling. The hind paw volume was measured        by UGO Plethysmometer 7149 measuring system. The final volume        data was normalized with the average body weight (ml/kg) and        edema was defined as the increase in paw volume on the day of        measurement relative to day 0.

Results:

FIG. 1 shows the body weight changes in the 4 groups of rats. Bodyweight loss was observed on day 16 in all 4 groups of rats, whichcoincided with the onset of arthritis. The body weight loss continuedfrom day 16 to day 19.

After the IA injection on day 19, a more pronounced weight loss wasobserved in the sustained release composition 1 and sustained releasecomposition 2 groups, compared to the saline and free DSP groups. Theweight loss could be caused by the loss of appetite, a known side effectof steroid. As the DSP was released from the sustained releasecompositions at a slower rate, the side effect of the steroid (loss ofappetite) lasted longer. Hence, a more noticeable weight loss wasobserved in the groups receiving sustained release compositions.

FIG. 2 shows the change in clinical visual arthritis score in 4 groupsof rats. Prior to the IA injection, the average score was 3.75 for thesaline group, 4.0 for the free DSP and the sustained release composition2 groups, and 4.25 for the sustained release composition 1 group.

24 Hours after the IA injection, the score dropped below 1 for all ofthe groups, except the saline group.

For the free DSP group, the score increased slowly 48 hours after the IAinjection. The arthritis symptoms became more severe and the scorereached 4.5 on day 26.

The rats in the sustained release composition 1 and sustained releasecomposition 2 groups showed no arthritis symptoms for the following 4days, with a score of 0 on days 23 and 24. On day 26, three rats in thesustained release composition 1 developed mild arthritis symptoms withan average score of 1.5, whereas no rat in the sustained releasecomposition 2 group had any relapse symptoms, with the score remainingat 0. The rats in the free DSP group on day 26 had severe arthritissymptoms and a score of 4.5. On day 30, the rats in the sustainedrelease composition 1 group developed severe arthritis, with a scoreabove 4, whereas the rats in the sustained release composition 2 grouphad mild arthritis with a score of 1.5.

Referring to FIG. 3 and FIG. 4, after the IA injection on day 19, pawswelling volume decreased in all 4 groups on day 20. The temporaryreduction of paw swelling volume in the saline group may have been dueto the dilution of inflammatory factors by saline in the joint.

For the free DSP group, the effect of the IA injection lasted for 3days. On day 23, both paws were swollen again, with the thickness around7.5 ml/kg.

For the sustained release composition 1 group, paw swelling reducedsignificantly for the next 4 days. Both paws became swollen again on day25, with an estimated thickness around 7.5 ml/kg.

1 For the sustained release composition 2 group, paw swelling reducedsignificantly for the next 10 days. Both paws became swollen againaround day 34, and the thickness was above 8 ml/kg for the right ankleand 7.5 ml/kg for the left ankle.

The study described above supported a conclusion that a single IAinjection of the sustained release composition was more effective intreating arthritis in experimental animals, as compared to free DSP.

Example 4. Multiple Injections of Sustained Release Composition forTreating Arthritis

The design of this study is substantially similar to that of the studydescribed in Example 3, except (a) there was no saline control group;and (b) study medication was administered by IA injection once a day for4 days (day 26 to day 29).

Results:

FIG. 5 shows the change in body weight in the 3 groups of rats (free DSPgroup, sustained release composition 1 group and sustained releasecomposition 2 group). Body weight loss was observed on day 24 in all 3groups of rats, which coincided with the onset of arthritis.

After the IA injections from day 26 to day 29, a more pronounced weightloss was observed in the 3 groups. As discussed in Example 3, the weightloss could be caused by the loss of appetite, a known side effect ofsteroid.

FIG. 6 shows the change in clinical visual arthritis score in the 3groups of rats. Prior to the IA injections, the average score was around4.5 to 4.7.

For the free DSP group, the score dropped to 3 on day 30, the lowestrecorded score in this study. The arthritis signs soon relapsed andbecame severe on day 33.

For the sustained release composition 1 and sustained releasecomposition 2 groups, the arthritis score continued to decline after thetreatment ended on day 29 and remained at zero (0) until day 37. In thesustained release composition 1 group, the rats first showed signs ofrelapse on day 40, whereas in the sustained release composition 2 group,the rats first showed signs of relapse on day 42.

Referring to FIG. 7 and FIG. 8, paw swelling volume decreased in bothpaws across the 3 groups after 4 daily IA injections. For the free DSPgroup, the effect of the IA injection lasted for 1-2 days. On day 31,both paws were swollen again, reaching the peak on day 40.

For the sustained release composition groups, paw swelling reducedsignificantly for the next 14 days. In the sustained release composition1 group, the first sign of paw swelling was noted on day 40 whereas inthe sustained release composition 2 group, the first sign of pawswelling was noted on day 42.

The study described above supported a conclusion that 4 daily IAsustained release DPS injections were effective for treating arthritisin the experimental animals.

Example 5. Indomethacin Sustained Release Composition

Indomethacin sodium (Hubei Heng Lu Yuan Technology Co., Ltd, Hubei,China) was dissolved with saline to a final concentration of 5 mg/ml.The lyophilized liposome mixture described in Example 1 wasreconstituted with 0.3 ml of indomethacin solution, resulting inindomethacin sustained release composition of reconstituted volume of0.3 ml per vial, with the final concentrations of 5 mg/ml INN, 71 mg/mlDOPC, 8 mg/ml DOPG, 13 mg/ml cholesterol and 50 mg/ml mannitol.

Example 6. Collagen-Induced Arthritis Animal Model Used in theExperimental Study of Indomethacin Sustained Release Composition

An in vivo evaluation of the effect of the indomethacin sustainedrelease composition on arthritis was performed using 18 female Lewisrats (BioLASCO Taiwan Co. Ltd., Taiwan). The study design and theinduction of arthritis in rats were substantially similar to that of thestudy in Example 3.

The arthritis treatments were initiated at the peak of the clinicalvisual arthritis score, which occurred at day 19. Eighteen rats wererandomly divided into three groups (6 rats in each group): (1) controlgroup (without any treatment, labeled “Control” in FIG. 9): (2) freeindomethacin group (2 mg/kg indomethacin per dose, labeled “Indomethacin(2 mg/kg) in FIG. 9); and (3) indomethacin sustained release compositiongroup (2 mg/kg indomethacin per dose; labeled “Indomethacin-BioSeizer (2mg/kg) in FIG. 9). The rats in each group were given no treatment(control group), daily subcutaneous injection around the arthritisjoints of free indomethacin or indomethacin sustained releasecomposition, from day 19 to day 23. The dose of indomethacin in theadministered compositions is listed in Table 4.

Table 4. The dose of free indomethacin solution and indomethacinsustained release composition.

TABLE 4 Indomethacin Free Indomethacin Item Sodium Conc. Sodium Conc.Free Indomethcin Solution   5 mg/ml   5 mg/ml Indomethacin sustained4.65 mg/ml 3.36 mg/ml release composition

The rats in this study gained body weight from the beginning of thestudy, and reached the peak on day 12. Body weight decreased in allthree rat groups, as the signs of arthritis developed. Arthritis scorereached its maximum on day 18, with the average arthritis score between7.2-7.4, as illustrated in FIG. 9 b.

From days 19 to 23, the arthritis symptoms were reduced in groups 2 and3. In group 2 (free indomethacin group), the average arthritis scoredropped from 7.4 to 5, with improved motor function and increased kneejoint flexibility on day 20. On day 25, 2 days after the termination ofthe indomethacin treatment, signs of arthritis (such as stiff, swollenand erythematous joints) relapsed and the arthritis score reached 8.

In group 3 (indomethacin sustained release composition group), theaverage arthritis score decreased from 7.6 to 5.8 on day 20. Thearthritis score remained under 7 until day 29 with prolonged treatmentefficacy after the termination of treatment. The arthritis symptoms ofgroup 3 became severe on day 30.

In summary, during the 5-day treatment of free indomethacin (group 2) orindomethacin sustained release compositions (group 3), arthritissymptoms were significantly ameliorated in both groups. Arthritis signsreturned two days after the withdrawal of free indomethacin in group 2,whereas in group 3, the amelioration of arthritis signs continued for 6days after termination of the treatment. The results of the studysummarized above support a conclusion that the indomethacin sustainedrelease composition maintains the efficacy of indomethacin in the jointfor a longer period of time than free indomethacin.

Example 7. Etanercept Sustained Release Composition

Lyophilized liposome mixture described in Example 1 was reconstitutedwith 0.3 ml of Enbrel (50 mg/ml of etanercept, commercially availablefrom Wyeth Pharmaceuticals. Inc., Collegeville, USA), resulting in anetanercept sustained release composition with reconstituted volume of0.3 ml per vial. The final concentration of lipid and etanercept in theetanercept sustained release composition is: 42.8 mg/ml etanercept, 70.7mg/ml DOPC, 8 mg/ml DOPG, 13 mg/ml cholesterol and 50 mg/ml mannitol.

Example 8, Collagen-Induced Arthritis Animal Model Used in theExperimental Study of Etanercept Sustained Release Composition

An in vivo evaluation of the effect of the etanercept sustained releasecomposition on arthritis was performed using 18 female Lewis rats(BioLASCO Taiwan Co, Ltd., Taiwan). The study design and the inductionof arthritis in rats were substantially similar to that of the study inExample 3, except bovine type II collagen was administered on day 0, day7 and day 17.

The arthritis treatments were initiated at the peak of the clinicalvisual arthritis score, which occurred at day 23. Eighteen rats wererandomly divided into three groups (6 rats in each group): (1) controlgroup (without any treatment, labeled “Control” in FIG. 10); (2) freeetanercept group (50 mg/kg etanercept per dose, labeled “Enbrel (50mg/kg) in FIG. 10); and (3) etanercept sustained release compositiongroup (50 mg/kg etanercept per dose; labeled “Enbrel-BioSeizer (50mg/kg) in FIG. 10). The rats in each group received no treatment or twosubcutaneous injections around the arthritic joints of free etanerceptor etanercept sustained release composition, on day 23 and day 26. Thedose of etanercept in the administered compositions is listed in Table5.

Table 5. The dose of free etanercept solution and etanercept sustainedrelease composition.

TABLE 5 Item Etanercept Conc. Free Etanercept Conc. Free EtanerceptSolution   50 mg/ml   50 mg/ml Etanercept sustained release 42.8 mg/ml40.3 mg/ml composition

The rats in this study developed signs of arthritis soon after type IIcollagen immunization and reached the peak on day 23, with the averagearthritis score between 3.6 to 3.8, as illustrated in FIG. 10.

During the treatment period (day 23 to 26), the signs of arthritis werereduced in the treatment groups (groups 2 and 3). In group 2 (freeetanercept group), the average arthritis score dropped to 2.4 on day 26but arthritis relapsed 3 days after the termination of the freeetanercept. On day 30, the arthritis score reached 4 and the rats becameimmobile due to joint swelling and stiffness.

In group 3 (etanercept sustained release composition group), the averagearthritis score decreased to 2.2 on day 26 and remained under 2.5 untilday 32. The arthritis symptoms of group 3 became severe again on day 33.

In summary, during the 4-day treatment of free etanercept (group 2) oretanercept sustained release compositions (group 3), arthritis symptomswere significantly ameliorated in both groups. Arthritis signs returnedthree days after the withdrawal of free etanercept in group 2 whereas ingroup 3, the amelioration of arthritis signs continued for 5 days afterthe termination of the treatment. The results of the experimental studysummarized above support a conclusion that the etanercept sustainedrelease composition maintains the efficacy of etanercept in the jointfor a longer period of time than free etanercept.

Example 9. Methotrexate Sustained Release Composition

The lyophilized liposome mixture described in Example 1 wasreconstituted with 0.3 ml of methotrexate sodium (Pharmachemie BV,Inc.), resulting in a methotrexate sustained release composition with areconstituted volume of 0.3 ml per vial. The final concentration oflipid and methotrexate in the methotrexate sustained release compositionis: 2.5 mg/ml methotrexate, 70.7 mg/ml DOPC, 8 mg/ml DOPG, 13 mg/mlcholesterol and 50 mg/ml mannitol.

Example 10. Collagen-Induced Arthritis Animal Model Used in theExperimental Study of Methotrexate Sustained Release Composition

An in vivo evaluation of the effect of the methotrexate sustainedrelease composition on arthritis was performed using 18 female Lewisrats (BioLASCO Taiwan Co, Ltd., Taiwan). The study design and theinduction of arthritis in rats were substantially similar to that of thestudy in Example 3, except bovine type II collagen was administered onday 0, day 7 and day 17.

The arthritis treatments were initiated at the peak of the clinicalvisual arthritis score, which occurred at day 23. Eighteen rats wererandomly divided into three groups (6 rats in each group): (1) controlgroup (without any treatment, labeled “Control” in FIG. 11a ); (2) freemethotrexate group (1 mg/kg methotrexate per dose, labeled “Methotrexate(1 mg/kg) in FIG. 11a ); and (3) methotrexate sustained releasecomposition group (1 mg/kg methotrexate per dose; labeled“Methotrexate-BioSeizer (1 mg/kg) in FIG. 11a ). The rats in each groupwere given no treatment (control group) or two subcutaneous injectionsaround the arthritic joints of either free methotrexate or methotrexatesustained release composition, on day 23 and day 26. The dose ofmethotrexate in the administered compositions is listed in Table 6.

Table 6. The dose of free methotrexate solution and methotrexatesustained release composition.

TABLE 6 Methotrexate Free Methotrexate Item Sodium Conc. sodium Conc.Free Methotrexate Solution 2.5 mg/ml 2.5 mg/ml Methotrexate sustainedrelease 2.3 mg/ml 1.8 mg/ml composition

The rats in this study developed signs of arthritis soon alter type IIcollagen immunization and reached the peak on day 23, with the averagearthritis score between 3.4 to 3.8, as illustrated in FIG. 11 b.

From days 23 to 26, the arthritis symptoms were reduced in groups 2 and3. In group 2 (free methotrexate group), the average arthritis scoredropped from 3.7 to 1.4 on day 26. On day 30, 4 days after thetermination of methotrexate treatment, the rats became hypoactive andthe arthritis score reached 3.5.

In group 3 (methotrexate sustained release composition group), theaverage arthritis score decreased from 3.4 to 1.6 on day 26. Thearthritis score remained around 2 until day 35, and increased afterthat.

In summary, methotrexate treatment ameliorated arthritis symptoms ingroup 2 and 3. Arthritis signs returned 4 days after the withdrawal offree methotrexate in group 2, whereas in group 3, the amelioration ofarthritis signs continued for 9 days after the termination of thetreatment. The results of the experimental study summarized abovesupport a conclusion that the methotrexate sustained release compositionmaintains the efficacy of methotrexate in the joint for a longer periodof time than free methotrexate.

Different arrangements and combinations of the elements and the featuresdescribed herein are possible. Similarly, some features andsubcombinations are useful and may be employed without reference toother features and subcombinations. For example, if a method isdisclosed and discussed and a number of modifications that can be madeto a composition included in the method are discussed, each and everycombination and permutation of the method, and the modifications thatare possible are specifically contemplated unless specifically indicatedto the contrary. Likewise, any subset or combination of these is alsospecifically contemplated and disclosed. Various embodiments of theinvention have been described in fulfillment of the various objectivesof the invention. It should be recognized that these embodiments aremerely illustrative of the principles of the present invention. Numerousmodifications and adaptations thereof will be readily apparent to thoseskilled in the art without departing from the spirit and scope of thepresent invention.

1. A method of treating arthritis, comprising: intraarticularlyinjecting a composition into a joint of a subject in need of treatmentfor arthritis, said composition comprising: a mixture of a firstphospholipid and a second phospholipid, the first phospholipid beingphosphatidylcholine (PC), and the second phospholipid beingphosphatidylethanolamine (PE) or phosphatidylglycerol (PG); and one ormore therapeutic agents.
 2. The method of claim 1, wherein the liposomescomprises a mixture of a first phospholipid and a second phospholipid,the first phospholipid being1,2-dioleoyl-sn-glycero-3-phosphatidylcholine (DOPC),1-palmitoyl-2-oleoyl-sn-glycero-3-phosphatidylcholine (POPC), soyphosphatidylcholine (SPC), or egg phosphatidylcholine (EPC) and thesecond phospholipid being polyethyleneglycoldistearoylphosphatidylethanolamine (PEG-DSPE) ordipalmitoylphosphatidylglycerol (DOPG).
 3. The method of claim 1,wherein said composition comprises cholesterol at a mole percent ratioabout 10 to about 33 based on the total amount of the firstphospholipid, the second phospholipid and cholesterol.
 4. The method ofclaim 3, wherein the first phospholipid is DOPC and the secondphospholipid is DOPG.
 5. The method of claim 3, wherein the compositionis prepared by reconstituting a lyophilized lipid cake comprising saidmixture of the first phospholipid and the second phospholipid andcholesterol with an aqueous solution comprising said one or moretherapeutic agents to form an aqueous suspension.
 6. The method of claim3, wherein the composition is prepared by reconstituting a lyophilizedcombination of said one or more therapeutic agents and a lipid cakecomprising said mixture of the first phospholipid and the secondphospholipid and cholesterol with an aqueous solution to form an aqueoussuspension.
 7. The method of claim 1, wherein the therapeutic agentcomprises a water-soluble steroid or a pharmaceutically acceptable saltthereof.
 8. The method of claim 7, wherein the water-soluble steroid isdexamethasone sodium phosphate (DSP).
 9. The method of claim 7, whereinthe water soluble steroid has a potency equivalent from about a 2 mgdose to about 8 mg dose of dexamethasone.
 10. The method of claim 1,wherein the therapeutic agent comprises a nonsteroidal anti-inflammatorydrug or a pharmaceutically acceptable salt thereof.
 11. The method ofclaim 10, wherein the nonsteroidal anti-inflammatory drug or thepharmaceutically acceptable salt thereof is indomethacin or indomethacinsodium.
 12. The method of claim 10, wherein the concentration of thenonsteroidal anti-inflammatory drug or the pharmaceutically acceptablesalt thereof is about 4.65 to about 5 mg/ml.
 13. The method of claim 1,wherein the therapeutic agent comprises a disease modifyinganti-rheumatic drug (DMARD).
 14. The method of claim 13, wherein theDMARD comprises a TNF-a antagonist.
 15. The method of claim 14, whereinthe TNF-a antagonist is etanercept.
 16. The method of claim 15, whereinthe concentration of etanercept in the composition is about 42.8 mg/mlto about 50 mg/ml.
 17. The method of claim 14, wherein the TNF-aantagonist is adalimumab.
 18. The method of claim 13, wherein the DMARDcomprises methotrexate or a pharmaceutically acceptable salt thereof.19. The method of claim 18, wherein the pharmaceutically acceptable saltis methotrexate sodium.
 20. The method of claim 18, wherein theconcentration of methotrexate or the pharmaceutically acceptable saltthereof is about 2.3 to about 2.5 mg/ml.
 21. The method of claim 1,wherein the therapeutic agent is encapsulated in an aqueous medium ofthe liposomes.